Mental disorders in epilepsy

tory, and frequently good control over seizures distracts the attention of doctors even “from the significant emotional disorders”, which take place without changes in the consciousness, and also “from the anxiety connected with them”.

According to N. Tatishvili et al. (1997), in a number of patients with rare tonic-clonic and myoclonic seizures occurring benign since the youthful period for 30 to 55 years, “the natural history of the disease,” demonstrates the possibility of confusional states at a certain stage, already in “adulthood . “

Study of psychopathology in people with epilepsy, according to D. Taylor (1997), is of great importance not only to provide them with specific assistance, but also for audit and scientific comprehension approaches to the treatment of epilepsy.

As it is pointed out by V. Bourgeois (1997) and G.A. Baker et al. (1997), ssessment of the impact of the abolition of antiepileptic drugs on cognitive function and behavior of patients and today ranges from ignoring to revaluation, and indications for use of these funds in the balance depending on the predominance of one or another point of view.

Given data confirms insufficiency and unsystematic nature of the illumination of questions of clinical and social prognosis within this pathology.

In the period from 1971 to 1991 we carried out the studies, common purpose of which were the clinico-catamnetic characteristic of the dynamics of the epileptic disease, which takes place with the mental disorders, and the development of the corresponding clinical criteria of social-labor prognosis.

In particular, was studied the psychopathological structure of various forms of epileptic psychoses and dementia, were isolated the clinical regularities, which characterize the special features of the dynamics of mental, including the so-called nonpsychotic disorders with epilepsy. Were also revealed the factors, which cause the variety of structure and dynamics of epileptic psychoses and dementia, were identified the factors, which determine the possibilities of the sociallabor adaptation of patients with various forms of mental pathology with epilepsy. The attempts to systematize varied psychopathological manifestations with epilepsy for purposes of the substantiation of their assumed pathogenesis and to develop the clinical criteria of the expert estimation of the ability to work of patients were undertaken also. The results of the carried out work are represented in the following chapters.

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Chapter 2

EPIDEMIOLOGY

OF MENTAL DISORDERS

OF EPILEPSY

The main reason for the absence up to date of a single classification of mental disorders in epilepsy can be considered the fact that the approaches to the taxonomy of these disorders are very heterogeneous. The last, although ccould be due to the diversity of problems facing researchers and therefore the need to build appropriate classifications, but at the same time indicates the prevalence of far more analytical than synthetic (more than necessary in order to prognosis) approach to the problem.

Apparently, this type of a gap in a study of epilepsy, is caused an explicit contradiction between the data of the statistical reports of the psychoneurological establishments, in accordance with which the psychoses and dementia are observed by the doctors almost in each second adult patient with epilepsy, and by literature data, in accordance with whom the prevalence of productive and negative psychopathological disorders with epilepsy varies over wide limits – from 3,8 to 60% (R. de Smedt, 1983; K.W. Bash et al., 1979,1984; V. Cosi, 1980; D. Blumer, 1982; V. Milev et al., 1989; O. Dorr Segers et al., 1983; Y. Fukushima, 1983; E.N. Reynolds, 1983; M.O. Abdulghani et al., 1997).

Anyway, according to modern authors, behavioral and mental disorders, which include depression, anxiety, attention disorders with hyperactivity, and psychotic disorders often occur in epilepsy (L. Forsgren et al., 1990; O.Devinsky, 2002; A.M.Kanner, 2002; C.L. Harden et al. 2004), and psychoses – is 6-12 times more frequent (E Cankurtaran et al., 2004; Montagne D., 2009), than in the general population.

Attempts to systematize the various manifestations of epileptic psychoses can be divided into the following.

Traditional approach, mainly based on the statistical description of the manifestations of epileptic psychoses. Here can be referred the

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classification schemes, which distribute these states according to the sign of presence or absence of one or other psychopathological syndrome or another (E. Esquirol, 1838; A. Gastaut, 1975; G.K. Koehler, 1977), the degree of the manifestation of any general for many states phenomenon (V.A. Muratov, 1900; P.A. Yudelevich, 1941; G. Bogliun et al., 1997), the duration of psychosis (P. Samt, 1875; R. KrafftEbing, 1883; P. Flor-Henry, 1963; J.H. Bruens, 1971). The attempts to establish the electrophysiological correlate of separate psychotic disorders without the correlation of the latter with the entire totality of their forms are involved here to the known degree (H. Landolt, 1955; H. Helmchen, 1970; L. Diehl and H. Helmchen, 1973; M.O. Abdulghani et al., 1997; O. Aleksic et al., 1997). Without the comparison with the dynamics of disease in general even such dynamic characteristics, as the form of the course of psychosis, are received in this case as something fixed and being insignificant for the prognosis (M.K. Tsaune and M.Ya. Upenietse, 1972; G.H. Christodoulou, 1978; G.B. Abramovich and R.A. Kharitonov, 1979).

Another, also traditional in recent decades approach, has become an approach to classification of epileptic psychosis by their comparison with paroxysmal disorders in time of manifestation of psychotic disorders. Many authors, mainly neurologists, isolated ictal (or intraictal), periictal, postictal and interictal (or chronic) epileptic psychoses. However, only some of them without sufficient evidence try to justify the existence of this scheme by clinical interpretation, pointing out that ictal psychosis are psychotic manifestations of complex partial seizures, that postictal psychosis is psychosis, resembling different duration affective-delusional psychosis in schizophrenia, and that interictal chronic psychosis are chronic schizophrenia-like epileptic psychoses. Considering that paroxysmal disorders with the epileptic disease are repeated at the subclinical or clinical level during the entire life of patient, then becomes incomprehensible very principle of the isolation of the postictal and interictal psychoses, including pathogenetically or of those of chronologically connected or not connected with the seizure.

More productive allocation criteria for social forecasting approach to the classification of epileptic psychoses should be considered an establishment of correlations between the type of personality and behavioral disorders and psychotic forms (Ya.V. Berenshteyn, 1936; Ya.P. Frumkin, 1938; A.S. Kronfeld, 1938; A.A. Perelman, 1938; J.H. Bruens, 1971; M.Ya. Upenietse, 1974; M. Derouaux et al., 1997).

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However, this method of classification is not free from the prognostic mistakes, since the special features of the personality of patient either understood here out of the context of dynamics (more frequently there are in the form the so-called premorbid special features, or, on the contrary, the special feature of the personal manifestations of patient for the period of his inspection – as the consequence of disease), or personal, behavioral and cognitive disorders are examined out of their interrelation.

Probably, the examination of structure and dynamics of psychotic and nonpsychotic mental disorders in their correlation with type and stage of the course of disease should be recognized as more adequate for the development of the criteria of prognosis (G.I. Bershteyn, 1937; E.K. Krasnushkin, 1936; N.G. Kholzakova, 1939; M.F. Taltse, 1951; R.G. Gismatulina, 1959; E.B. Smyshlyaev, 1960; E. Glithero et al., 1963; R.G. Golodets and I.G. Ravkin, 1966; V.N. Favorina, 1969; A.V. Utin, 1970). However, the application of this principle can be effective only with the condition for its complete observance. Inconsistency in the application of this principle of classification of mental disorders in epilepsy leads to the study of only certain aspects of a problem. For example, to study the disease and the correlation forms of psychosis, psychosis and dementia ratio, the connection of the severety of epileptic process flow on the period of observation of the patient with the structure and shape of the flow psychosis, etc.

The principle of our classification is that the basic flow pattern of psychosis – transient, schubweise and chronic – we consider not only taking into account the structural and dynamic diversity of the clinical picture of the disease in each of these forms, but also with regard to the type and stage of the flow in epilepsy as a whole. In other words our attempt to examine structure and formation of epileptic psychosis in the course of the development of epileptic process throughout its duration. During the study of clinical material we established that the psychotic pictures with the epileptic disease are developed mainly under the conditions of three types of its course: favorable, with the set aside exacerbation of process and unfavorable.

The presence of the favorable course of disease was determined by us based on a relatively late clinical manifestations, uniform frequency and low variability in the structure of seizures, prevalence in the personality structure in the observed patients with hypersocial features and prolonged their disability.

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Here should be noted, however, a certain divergence between the psychiatrists and the neurologists in understanding “of the favorableness” of the course of epilepsy: last more frequently evaluated as favorable prognosis on the basis only of the dynamics of paroxysmal syndrome. In 1987. K. Watanabe for the first time described 9 cases of disease in children with the complex partial seizures with the favorable outcome. Later other authors confirmed the results of his study, and term favorable partial epilepsy in children was proposed for this “new” epileptic syndrome. Between 1993 and 1996 A. Berger et al. (1997) diagnosed favorable partial epilepsy in 13 of 2000 inspected children and on this base established its comparative rarity. G. Braathen et al. (1997) connected the following age, clinical and electrophysiological data in the sick with epilepsy children: at the age of up to 10 years – favorable partial epilepsy with the rolandic spikes and the simple partial seizures, while at the more elder age – only with the rolandic spikes.

The set aside exacerbation of epileptic process we determined on the relatively favorable at first development of the disease and the subsequent appearance of the polymorphism of paroxysmal disorders, the appearance of signs of dementia and a gradual decrease in the level of the social-labor adaptation of patients.

To this set of features , apparently , should include cases of socalled secondary generalized seizures. J.U. Lee et al. (1997) in the period from 1989 until 1994 formed group of 58 adult patients with temporal epilepsy with the relatively frequent secondary generalized seizures with the regular therapy (more than 5 during the year). According to the data of K. Wada et al. (1997), the recovery of tonic-clo- nic seizures after 10-29-years interruption occurs in the patients with epilepsy at the age from 19 to 74 years, and it is usually connected with “poor or intermittent answer” to the antiepileptic therapy.

The unfavorable course of disease, according to our data, is manifested in patients in the early appearance of seizures, their series, relatively rapid formation (into 5-10 years) of epileptic dementia, expressed decrease in the level of social-labor adaptation.

According to literature data, the majority of the cases of complex partial seizures with the beginning at the age of up to 2 years were always associated with the poor prognosis (A. Berger et al., 1997). Changes of semiology of seizures in the course of disease, seizures with the fall, worsening in the psyche and patterns of second bilateral synchronism on the electroencephalogram – A. Cerullo et al. (1997) characterized a “resistance epilepsy with the progressive epileptic

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involvement of brain”. Based on the example of 207 children with the seizures, which begun at the age of 3-11 years, after the period of their observation for 5-10 years Z. Martinovic et al. (1997) evaluated “early or deferred prognosis” as unfavorable with the appearance in them of behavioral, personal and cognitive disorders.

For structural and dynamic analysis of mental disorders with epilepsy it was expedient to separate the stage of the development of disease in the dependence on the presence or predominance in the clinical picture of three basic syndromes: paroxysmal syndrome, psychosis and dementia. They were related to these stages: the stage of the development of disease before the appearance of signs of psychosis, the stage of the development of psychopathological disorders before the appearance of dementia and the stage of disease, at which occurred further joint development of productive and negative psychopathological disorders.

Since on the last of these stages the clinical manifestations of disease are characterized by polymorphism and depend, first of all, on the dynamics of negative disorders, it was acknowledged necessary for purposes of the search for the criteria of the more visible in the time prognosis to divide this stage of disease into three independent stages. The first – with the combination of the signs of psychosis and dementia, in structure of which predominate the expressed affective disorders. The second – with the combination of the signs of psychosis and dementia with the predominance in its structure of mental disturbances. The third – with the combination of the signs of psychosis and dementia, structural special feature of which is the predominance of mnestic-intellectual disorders.

For this purpose we used such obligatory signs of epileptic dementia as the steadfast and expressed reduction in the critical functions, significant mnestic disorders, which are combined in patients with the crude violations of thinking, expressed by personal changes according to the epileptic type, by affective disorders.

It should be noted that in recent years a number of the authors, using a term “mental of retardation”, divide it in epilepsy into “severe” and “deep” (M. Derouaux et al., 1997). Others, carrying out the neuropsychological inspection of patients with epilepsy, indicate the presence in them “cognitive scarcity predominantly in the spheres of memory, attention and performance” (O. Aleksic et al., 1997).

Structure and dynamics of the remissions, which were being observed in the course of the development of various forms of psychoses

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required special examination in the course of our studies. However, in connection with their extremely diverse clinical design their separation into the independent stage of disease proved to be difficult. Taking this into account, the dynamic and structural analysis of remissions in the psychotic symptomatology was conducted within the indicated above basic stages of disease.

Considering the fact that followed by S N. Davidenkov (I960) epilepsy is considered by the contemporary authors as polyethiological disease with the united pathogenesis, the development of the connection between the fundamental characteristics of the development of disease and the assumed etiological factors was carried out by us taking into the account the assumption about the fact that the beginning of action on the organism of varied unfavorable factors in younger age can have an effect on the development of disease throughout its course.

This assumption in recent years has been confirmed in the concept of reducing the “neurological maturation” in patients with epilepsy, defined as muscle tone, synkineses and fine motor coordination, lack of verbal manipulative ability (O. Aleksic et al., 1997; S.L. Moshe, 1997). In 20 of 26 inspected children with the uncontrollable epileptic seizures D. Besana et al. (1997) revealed deviations in the formation of the brain in the form of encephalopathy, cerebral disgenesia, phakomatosis and metabolic disorders. In children, suffering Lennox-Gastaut-Syndrome, S. Ehlers et al. (1997) noted delay in the motor and vocal spheres.

During the study the prognostic importance of the forms of paroxysmal states we used the based on electroencephalographic data classification of the epileptic seizures of International antiepileptic leagues of 1969. Our data relating to the long-term prognosis was compared with etiologic and pathogenetic criteria contained in the classification of epilepsy and epileptic syndromes, adopted by the International League of antiepileptic in 1989.

Study of adaptation possibilities in epileptic patients we performed by comparing the actual level of their social order with prevailing at some stage or other clinical manifestations of the disease. In this case was considered not only the duration of a stay of a patient in the family, under the conditions of therapeutic-production workshops or usual works, but also the nature of adaptation under the indicated conditions. The latter was determined according to the productivity of patients in the work, the degree of preservation of the

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everyday working and professional habits, circle of interests, feeling of debt, responsibility, positive social installations, as well as the degree of dependence on others for addressing current issues in a changing environment.

It is necessary to note that the dependence of the level of the social adaptation of the patients with epilepsy on the sociocultural factors N.E. Bharucha et al. (1997), J.S. MacLeod et al. (2003) connect with the phenomenon of their stigmatization in the population. The latter, for example, in Asian cultures is especially sensitive to “contamination of personality and family” in connection with superiority of the marriage over other values.

At the same time K. Malmgren et al. (2003) and E. Pataraia et al. (2005) carry social problems and stigmatization to the number of most significant problems of the patients with epilepsy in the developed countries of Europe.

Decrease of fertility in women with epilepsy in the European country A. Georgi et al. (1997) are inclined to explain in the larger measure by the individual and social factors, such as unmarried state, rather than financial and educational. J. Groselj (1997) also notes the existence of 67% of unmarried men with epilepsy , and only 37 % of unmarried women. Important cultural differences are established by A. Jacoby and et al. (1997) and S. Kochen et al. (1997) in the countries of Europe not only on the quality of the life of those, who suffer epilepsy, connected with the conditions of stay or the relation to the treatment, but also with the overall cultural level of population and, in particular, the awareness of the social groups with respect to epilepsy. According to the data of A. Papavasiliou et al. (1997), children with epilepsy are a group that is vulnerable in terms of education.

In order to prognosis, we analyzed data on the effectiveness of drug therapy. Focused on analysis of forms and methods of treatment of epileptic psychoses were characterized, from the period of the 1950s, mainly by the combined use of neuroleptics, traditional and new antiepileptic drugs.

It should be noted that in recent years the reanimation of the interest of researchers in the study of therapeutic prognosis in the patients with epilepsy because of the more widespread introduction contemporary drug methods of treatment in the developing countries, where the morbidity by it two or three times higher than in the developed, is connected with the prevalence of the parasitizing infections. In the developing countries epilepsy as before is considered as severe

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illness together with leprosy and mental illnesses (N.E. Bharucha et al., 1997). One should, however, recognize that, as before, the discussion in this case mainly deals with the drug treatment of paroxysmal and behavioral disorders and with resistante epilepsy – the basic theme of the 22nd International congress for epilepsy. According to different data, resistante epilepsy comprises at present from 30 to 40% of all cases of disease.

The influence of the clinical special features of epileptic psychoses on the clinical and working prognosis was examined not only with regard to the type and stage of epilepsy, but also the stereotype of the development of productive and negative psychopathological disorders.

The arrangement of chapters in the present work is subordinated to the need of the sequential description of the development of the basic forms of mental disorders from the simplier to the more complex. This made it possible to reduce the number of repetitions during the formulation of the criteria of clinical and working prognosis.

First of all attention was paid to the study of the special features of structure and dynamics of mental disorders taking into account the dynamics of disease as a whole.

The total number of taken into account cases of epileptic disease composed 961 (478 – men, 483 – women).

A study was conducted in two stages. During the first stage the deep clinical development of 450 cases of epilepsy (234 men, 216 women), which takes place with the manifestations of psychosis was accomplished. On the second – verification obtained given on another population 511 adult patients with epilepsy with the mental disorders (244 men, 267 women), who lived in one administrative territory and who were being observed in one psychoneurological dispensary.

In the first cohort of patients 5 of 450 they were the invalids of the first group, 146 – second group, 83 – third group, 216 were able to work. Survey of 129 of them was carried out in the psychiatric department of the Central Scientific Research Institute of disability expertise and labor organizations of persons with disabilities in the period from 1971 to 1979. 96 of them were hospitalized, as out-pa- tients – 33 patients. The remaining cases ( 321 ) in the same period were analyzed based on a survey of patients contained in the acts of medical and labor examination and clinical supervision .

The presence in patients together with the epileptic seizures and changes in the personality according to the so-called epileptic type

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of any manifestations of psychosis, at least once noted in them during the disease, served as the criterion of the selection of the cases of disease for a special study of structure and dynamics of mental disorders.

The main method of research – clinical catamnesis. The development of disease as a whole in each case was analyzed. In this case were outlined the specific features of the adaptation of patients in their home and in the sphere of usual production. The diaries of observations of the patients in the period of their work under the conditions of therapeutic-production workshops and special shop were analyzed.

The period of catamnesis fluctuated widely: from 1 year to 42 years (13,3+/-0,6). Archive documentary data of inand out-patients in all cases were thoroughly analyzed. For refining the pathopsychological criteria of diagnostics of epileptic dementia an experimental-psycho- logical study of 200 patients was carried out (135 men, 65 women).

The materials of experiment, valuable for examination on clinical and working prognosis, were evaluated statistically with the application of a criterion of Student and associative coefficient of Yule.

The findings suggest that a variety of occupations in the patients examined. Many of them, despite the severity of the observed their psychopathology, over a long period were retained in the usual production. At the same time substantial part of the patients (45,1%) they were for the first time acknowledged by invalids at the age of up to 35 years.

Among the reasons for disablement there is “the disablement from the childhood” which composed only 16,7%. Already in the period of disease the part of the patients they could obtain the general and vocational education, they acquired the length of employment necessary for the pension guarantee and skilled labor was carried out before the offensive of disablement.

Our findings on the absence epilepsy significant differences between men and women by education level were confirmed in a report submitted S. Kochen et al. (1997) based on a study population of 1950 patients.

To clarify the role of the age factor in the development of the disease and its implications for the prognosis we examined patients of different age groups. Particular attention was paid to the so-called persons of working age (55 years for women and 60 years for men), whose numbers total of 434. At this age most often had to deal with questions of disability of patients and their rational employment.

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